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Abstract: The patient in this case was a 31-year-old Mr. Li, who had recurrent abdominal pain for 10 years. He had undergone colonoscopy and small intestinal microscopy suggesting an ulcer in the ileocecal region, and Crohn’s disease was considered, and this time, he visited the clinic with recurrent abdominal pain for 5 days and blood in the stool for 5 hours, and reexamined the colonoscopy: a huge ulcer suggesting a blind region. After detailed medical history, he had a history of oral ulcers and genital ulcers, and skin redness and swelling were seen at the site of blood sampling and infusion, which clearly diagnosed intestinal white stuffing, which could be clinically manifested as small intestinal ulcers. After treatment, Mr. Li’s abdominal pain was relieved and he did not have further blood in his stool.
Basic information】Male, 31 years old
Disease Type】Intestinal Leukocoria
Hospital】Dezhou People’s Hospital
Date of Consultation】January 2022
Treatment plan】Medication (mesalazine enteric coated tablets, injectable methylprednisolone sodium succinate, prednisone acetate tablets)
Treatment period】15 days of hospitalization
Treatment effect] Abdominal pain relieved, no more blood in stool
I. Initial consultation
The patient in this case was 31-year-old Mr. Li, who came to the emergency room for blood in the stool, and gastrointestinal bleeding is a common emergency and critical condition in gastroenterology, so he was immediately rushed to the emergency room. History: Mr. Li had abdominal pain for 5 days with sudden onset of blood in stool, the amount of blood in stool was not much, abdominal pain was obvious, mainly in the left upper abdomen, and the pain was severe. Mr. Li was given an abdominal examination, and the abdominal muscle was soft, which could initially exclude the problem of gastrointestinal perforation. When communicating with Mr. Li’s family about his condition, the tension of the family was also slightly relieved.
II. Treatment process
The ward was admitted, and Mr. Li and his family were asked in detail about his condition. Mr. Li self-reported that his medical history could be traced back to 10 years ago.
Ten years ago, he was hospitalized with recurrent episodes of abdominal pain with no obvious cause. The site of abdominal pain was not fixed, and the pain could be relieved by itself during the initial attack, but later the abdominal pain worsened and required pethidine hydrochloride tablets for pain relief. Colonoscopy: 2.0 cm diameter deep ulcer at the end of the ileum with yellow moss on the surface and nodular surrounding mucosa. The diagnosis of Crohn’s disease was made, and the pathology showed mucosal edema, moderate acute and chronic inflammation. Given mesalazine enteric tablets, injectable methylprednisolone sodium succinate treatment, symptoms improved, re-examination of endoscopic ulcer healing, there is the formation of scar, Mr. Li discontinued the drug on his own.
Seven years ago, abdominal pain reappeared, mainly in the lower abdomen, and the colonoscopy was repeated: still a large ulcer in the ileocecal region, and Crohn’s disease was considered. Pelvic CT showed: inflammatory changes in the ileocecal region and adjacent blind ascending colon. Crohn’s disease was most common in the small intestine, so further small bowel microscopy was performed, but no significant abnormalities were seen in the small intestine, and the pathology showed ulceration of the ileocecal valve without significant granulomas. Continuing with Crohn’s disease, mesalazine enteric tablets, dexamethasone sodium phosphate for injection, and pain relief and nutritional support were given, and Mr. Li was discharged after gradual improvement of abdominal pain. The ulcer was rechecked for healing, and Mr. Li again stopped the medication on his own.
Three months ago, he was treated with oral rivaroxaban tablets for popliteal vein thrombosis. This time, Mr. Li still had abdominal pain, which was predominantly abdominal pain for 5 days, and was treated with mesalazine enteric solution tablets on his own with no improvement in symptoms. 5 hours ago, he developed fresh blood stool with an amount of about 100 g. Detailed follow-up of Mr. Li’s medical history revealed that Mr. Li had recurrent oral ulcers since high school, recurrent genital ulcers, and on this admission, the skin at the site of the needle eye for blood sampling and infusion was red and swollen.
Relevant examinations of inflammation and immune indexes, screening for bacteria, EBV, CMV virus, and tuberculosis were performed (examination report below), and no evidence of bacterial, viral, or tuberculosis infection was seen. Abdominal CT examination: gastroscopy was apparently abnormal, and colonoscopy remained a huge ulcer in the ileocecal region with clear borders and covered with yellow and white moss. Pathological histological examination: numerous lymphocytes, plasma cells, neutrophils and scattered small amounts of eosinophil infiltration with microabscess formation, shortened and reduced crypt epithelium, and focal ulcer formation were seen in the whole mucosa. Antacid staining was negative, CMV was negative, and only one cell was seen positive for EBER.
Mr. Li’s diagnosis seemed to be clear. Although the pathology did not reveal the typical vascular inflammatory changes of intestinal leukocytes, the diagnosis should be intestinal leukocytes, and oral treatment with mesalazine enteric-coated tablets and glucocorticoids was selected, and injectable methylprednisolone sodium succinate was administered intravenously, followed by change to prednisone acetate tablets until decompensation.
Figure 1 Examination results
Figure 2 examination results
III. Treatment effect
In this case, Mr. Li belonged to mild to moderate intestinal white congestion, and after giving mesalazine enteric tablets and sodium methylprednisolone succinate for injection, the treatment was changed to oral prednisone acetate tablets, Mr. Li’s abdominal pain was relieved, no more blood in stool, weight gain, and the vitality of young people was restored again. In conclusion, Mr. Li was hospitalized for a total of 15 days, with relief of abdominal pain and no further blood in stool, and the treatment effect was good, and Mr. Li and his family expressed satisfaction.
IV. Notes
We are glad that Mr. Li’s abdominal pain disappeared after treatment, while intestinal leukoaraiosis, as an immune-related disease, cannot be cured at present, and there are currently drug applications to maintain its long-term remission, but it is easy to relapse after stopping the drug. Mr. Li had 3 episodes in 10 years, each with severe abdominal pain as the main manifestation, and this time he also developed blood in the stool, requiring medication to maintain treatment. The goal of treatment is to control the existing symptoms, prevent and control important organ damage, and slow down the progression of the disease. In daily life, Mr. Li needs to observe the presence of abdominal pain, diarrhea, blood in stool and other symptoms, and seek medical attention promptly if there are uncomfortable symptoms. In addition, in life, keep a relaxed mood, avoid spicy and stimulating diet, take medication on time, and keep a permanent contact with the doctor who also needs it.
V. Personal insight
Intestinal ulcerative lesions are becoming more and more common, and the differential diagnostic ability of doctors is more demanding. Detailed medical history, careful physical examination and complete auxiliary examination are still important bases for obtaining diagnostic clues. The incidence of leukoaraiosis is relatively low, rare in the comparison of intestinal lesions, and more difficult to differentiate from Crohn’s. For this case, Mr. Li has abdominal pain, diarrhea and blood in stool, which need to be combined with his overall condition, such as the presence of oral ulcers, vulvar ulcers, eye lesions, vascular lesions and neurological lesions. Mr. Li and his family need to keep records of their past conditions and visits for easy access by medical staff. For patients with the first occurrence, they need to differentiate from other intestinal ulcers and improve relevant examinations to achieve early diagnosis and treatment.